Anatomy of the Abdomen

Abdomen can be defined as the Region of the trunk that lies

between the Diaphragm above and the inlet of the pelvis
. below
:Structure at the Abdominal wall
Superiorly the Abdominal wall is formed by the Diaphragm
Inferiorly the Abdominal cavity is continuous with pelvis cavity
through the pelvis inlet of the pelvis below
Anteriorly the Abdominal wall is formed by : above by the lower
part of the thoracic cage and below by the Rectus
Abdomen ,external oblique internal oblique and the
transverses abdominis muscle and fascia
Posteriorly the abdominal wall is formed in the midline by the
five lumbar vertebrae
And their intervertebral Disc
Latterly : twelfth rib the upper part of the bony pelvis -
the poas muscle
The Abdomen is flexible dynamic contains housing most
of the organ of digestive system and the part of the
urogenital system
-: Abdominal lines and planes
Vertical lines and horizontal planes commonly used-
facilitate the description of the location these planes
: are
vertical plan 2/transpyloric plane 3/subcostal plane/1
intercristal plane 5/intertubercular plane/4
these lines divided the Abdomen into the nine region
-surface land mark of the abdominal viscera
the following organ are more or less fixed and their
surface marking one of clinical value
 -:Liver 

The liver lies under cover of the lower ribs and most of it is 
bulk lies on the right site
-: Gall bladder 

The fundus of the gall bladder lies opposite the tip of the 
right ninth costal cartilage
-: Spleen 

It is situated in the left upper quadrant and lies under cover 

of ninth ,tenth and eleventh ribs
It is long axis corresponds to that of tenth rib 

Pancreas :lies across the transpyloric plane the lies below 

and to the right,the neck on this plan,and the body and tail
lie above and to the left
-:Kidney 

The right kidney lies slightly at the lower level than left 
kidney
On the back the kidneys extend from the twelfth thoracic 
spine to the third lumber spine and the hili are opposite the
first lumber vertibra
Mechanism OF injury

two basic mechanisms :

1- blunt injury :-.
- occewed in collision with solid objects
Couses internal organ injury -

The severity of injury depends on the couse -

:Causes 

. Falls from hight .1

Motor vechile accident .2
These are the main causes of
. abdominal trauma
Causes multiple organ injury
:Other causes
Fight -
Bicycle -
These cause solitary organ injury
penetrating injury -2
:Blade *
Staping by knife is the most common
cause
- stap wound to the abd may be
: superfesial -
causing trivial ingury
- deep
Causing arapid death from bleceding
due to perforation of main abd .
vessels
:gunshot *
The damage may extent over awide
.area of the body
: The severity of injury depend on
Size of bullet -
Distance -
Death following injury

:Immediate death ( 50%) .1

Occurring immediately or within the first
.few min
:causes *
brain damage-
upper spinal cord damage-
damage to the heart OR major vessels-
.multiple injuries-
early death : ((30%)) -
occaring with in the the first few hours-
after inguny (( golden hocers of trauma ))
cause of early death *
air way obstruction -
lethal disruption of breathing mech anism -
massive blood loss (( circulatory collapse )) -
dysfunction of CNS due to intracranial -
heammoge
late death (( 20%))
.occurring days or weeks after injury -
-: causes *
sepsis -
. organ failure-
Causes of Death in
Abd. trauma
- resussefation
in adeguate volume of fluid or
- . blood
- miss diagnosis
- .failure to evaluate the p t
.delayed surgery -
.sepsis-
ASSESSMENT OF
TRAUMA (P. T.)

 Advanced trauma life support

(ATLS)
- primary survey and resuscitation:
 Identify and treat what killing the P. T.
- secondary survey:
 Identify all other injuries.
- definitive care or tertiary survey:
 Develop definitive mg plan
PRIMARY SURVEY AND
RESUSCITATION

 -airway with cervical spine protection:

 Airway obstructer if complete causes death within few
minutes.
 Simple maneuvers such as sweeping the index finger
around mouth to remove obstruction followed by chin lift
to remove tongue forwards clear the oro-pharynx can be
life saving.
 -Breathing and provision oxygen:
 in the absence of airway obstruction the failure of
breathing caused by :
 severe head injury.
 Direct damage to the thoracic wall.
 Tension pneumothorax.
 Massive pneumothorax.
 Open chest wound.
 -Circulation with control of bleeding:
 in absence of airway obstruction or tension
pneumothorax circulatory collapse is due to hemorrhage.
 The most common cause of shock after trauma is
hyporolaemia:
 Sign of shock are:
 Elevation of pulse rate.
 Fall in blood pressure.
 Fall in urine out put.
 Central cyanosis.
 Sweetness.
 Cold extremities
 -Disability:
 The level of conscious ness assessed by GCS
 -Exposure with control of environment any remaining
clothing should be removed and posterior surface of P. T.
examined without affect spine protection.
SECONDARY SURVEY
 Is full physical examination from head to toe.
 Trauma imaging x-ray - CT scan – MRI.

rectal examination and inspection of

perineum.
Definitive care and
tertiary survey
* It aims to reduce the incidence and morbidity of the missed
injuries.
* When the P. T. in ICU tertiary survey consist of another head
to toe examination and review all available laboratory and
imaging result.
investigation
A. general
B. Specific
Ultra sound & FAST .1
computed tomograghy ( CT scan) .2
radiology & angiograghy .3
others techinques.4
DPL .5
surgical exploration(laparotomy) .6
N.B indication of urgent laparotomy
Diagnostic Peritoneal Lavage
( DPL )

[Link]
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[Link] DPL
[Link] DPL
Definition

the most widely used diagnostic*

technique. Lavae has proved to be a
highly sensitive test for decting
intra-abdominal injury after blunt
trauma or stab wounds to the
anterior abdomen * the test is
invasive, non spesific & relatively
inaccurate in evaluting
retroperitoneal OR diaphragmatic
injury
Indication

patient with altered mental status or .1

neurological injury i.e (physical
examination may be falsely negative)
in particular patients with alcohol OR.2
.drug overdose
.suspected head injury .3
demonstrated spinal cord injury .4
Patients with fractures of the lower .5
ribs, pelvis or lumbar spine i.e (pts.
With falsely positive physical
examination )
Contraindication

pts. Who has hade multiple previous .1

abdominal operations because they
have adhesions of the small bowel to
the anterior abdominal wall that
prevent the save Insertion of the
lavage catheter into the abdominal
.cavity
Signs on physical examination indicating.2
the need for exploratory laparotomy
procedure

.Decompress the urinary bladder by inserting catheter.1

Small amount of local anesthetic is placed in the .2
midline of the abdomen (one third of the distance
. from the umbilicus to the symphysis pubis
Incision of skin , subcutaneous tissues & the .3
peritoneum is carefully incised while upper tension is
placed the anterior abd .wall with hemostats applied
. to the fascia
A peritoneal dialysis catheter is then iserted to the.4
peritoneal cavity
After 5 to 10 min, the fluid is siphoned off and send to.5
. the laboratory for examination
Specific Organs
Injuries
Gastric teaum
Mast gastric trauma are caused by
pene trating .gastoiic oupture
sccondany to blunt trauma is
.rare
Giastris can be caused interalyby
instrumentation endo tucheal ture
misplaced in the esophayus , hes
.ingestion of goreigr body
-:DIAGNOSIS
-:Gastorc penetration is usually snspected
.Epigadhic or left upper guardant injunies
Stomach mul be perforated her stap wounds te
.thechest, buck or lower abdomen
-:Evaluator is her lapratomy climicel prerertation
It the antersor wall of the stomach is penertraltd,
. the clinical sigr of peritoirtis areusually pregent
EPigastric pain , lever , leucouytiosis and vomiting
are signsof gaotric perforior hry anabdominl
stabwound unfortunately all there signs maf he
.abent
Grosi blood aspirate from maso gastrc tube is
.highly suggestive
 Management
- . Ressucitation
.Foley catheter -

Nasogrstric ture : valuable Fo both dicegnoitic -

reason and to limit the degoet oFperitoneal
.Soilage resulting from gastric pergorafion
-:AT Lapartory
.Stomach must be in pecfed from esophago
Gastric junchion to the pylorus and along both cer
.vatures
Gutic inuries can be treted with deboid ment Of
Close in layer . the defect should be closed in
two layers , inner lauyer of absorbrble material
of outer layer sutures non . absorbnble material
.
Gastrostory should be congidred ib prolonged
gastric decompression seem recessany of Ghere
. is strong lirlicfions
Gastric dirersion or regection is rarely recessarg
unless the amount of destouction is extensive
svch as with righ velocity gun shot
Spleen

:Anatomy
.lies in the left hypo chondrium -1
.it is intra pretoninl organ -2
. blood supply-3
:FUNCTIONS

immune function
filter function
cytoppoiesis
PLENIC RUPTUR S
:Cuases
`planter trauma
fracture over line ribs
iatrogenic
fall without any directed trauma to the trunk
stap wound
splenic puncture
-:Presentation
the pt succumbs rapidly
initially shock ,recovery, sings of late bleeding
delayed coma
-:Management

resuscitations
Prepare the Pt for the surgery
laprotomy
splenic preservation
facilitate inspection
surgical procedures according
tosplenic injury scale
:Bowel Injury
Intestinal injury may with or without an external wound*

With external wound (penetrating)

Without external wound (blunt)

-: Small intestine injury they are due to*

Crushing between vertebrae and the anterior abdominal
wall
Sudden increase in intra abdominal pressure

Tear at junction of mobile and fixed segment of the*

bowel
In 40% associated with other injury
In small perforation the mucosa may*
prolapse in addition there may be
.laceration in the mesentery
The Pt will have combination of intra*
abdominal bleeding and release of
intestinal content into abdominal
cavity give rise to peritonitis
Perforated small intestine exhibit some
evidence of peritoneal irritation and
may have frank abdominal rigidity
Minor tear is of little significant but*
large hematoma may ultimately with
little perforation
-: C OLONIC INJURY

Rare only in 5% of blunt-

abdominal trauma also associated
with other injury
Mainly transverse colon-
Incomplete laceration
(seromuscular) haemtoma
complete laseration with faecal
spillage and avulsion from the
mesentery
Investigation

DPL-
Abd x ray-
Barium enema CT scan-
LIVER
 The liver is largest orgam in the body.
 The liver is divided into large right lobe and small left
lobe.
 The liver trauma is uncommon because it is protected by
diaphragm and chest wall. How ever, when they do occur
the common area effect by trauma it’s right lobe
because it’s lager and less mobite.
The type o trauma:
-Penetrating trauma.
-Blunt trauma.
Diagnosis of liver injury:
 Because the liver is vascularised orgam and so blood the
major complication of liver injury.
 All liver chest and upper abdominal stab wounds should
suspect or crashing injury of per combine rib fracture.
Management:
 Initial management:
– -Resuscitate – it’s must important stage of:
Airway.
Breathing.
Circulation.
– -Assessment of injury:
– by:
- laboratory

- CT scan
Surgical approach to liver trauma:
 Good access is rital must be visualization of liver and spleem and if
necessary can be extending up work for median sternotomy.
 Stab incision, susturad by chromic absorobal.
 Ble monofilament surture.
 Laceration to hepatic artery should be identified and used atraumatic
clamp on proximal ressel prior to repair by prolrnr surture.
 If un avoidable can be lighted but the ligation many lead to abscess
formation.
 The blant trauma by sutuming and paclling diffuse parenchynal injury
tp produce haemostasis but the site effect pentiontis.
Complication of liver trauma:
 Intrahepatic hoematoma.
 Liver abscess.
 Bile collection.
 Biliary fistula.
 Hepatic artery aneurysm.
 Arterio venous fistula.
 Liver failure.
 Long term out come of liver trauma:
 Late complications are rare but development of biliary
tract stribure many years after recovery from liver
trauma.
 Hyper atrophy of the liver lobe because to do
compensatory.
 PANCREAS
 Pancreatic trauma is three types include blunt, penetrating and
laterogenic but pancreatic injury is uncommon.
 Pancreas is surrounded by major obdominal organs and blood
vessels so associated injuries are common eg stomach –
duodenum – spleen.
* How to evaluate pts?
 After primary survey “pulse – Bpr – Temperature – respiratory
rate” and secondary survey
 History – pts come with trauma and must:

– .Identify is it blunt or penetration.

– . Type of trauma eg accident, caliber, and gunshot.
– .Ask about velocity.
– .Identify site of trauma.
 O/E tenderness, rigid abdomen – distended abdomen –

temperature
* When do we suspect pancreatic injury?
- if pts come with epigastric pain
 investigation:
– .peritoneal lavage - amylase.
– .U/S show oedema - hematoma - pseudocyst.
– .Serum amylase may be elevated but limit
sensitivity for pancreatic injury because elevated in
16% of penetrating pancreatic trauma and 61% of
those with blunt trauma.
– .CT scan
– .Laboratory is indicated if there is persistent
abdominal pain and persistent elevated amylase.
CLASSIFICATION AND
MANAGEMENT

INJURY
INJURY DEFINITION TREATMENT
TYPE
Contusion and laceration without External drainage distal
I
duct injury pancretectomy

Distal transaction or parychymal

II Distal pancretectomy
injury with duct injury

Proximal transaction or parynchmal Distal pancretectomy or roux-en y

III
injury with palpable duct injury pancreatico susenectormy.

Combined pancreatic duodenal

IV Repair treat pancreas as I and II
injury, ampulla, blood supply intact.

Massive injury ampullo destroyed Pancreatico duodenectomy

 Complications:
 -Wound infection.
 -DM
 -Pancreatitis
 -Pancreatic fistulas: common site of fistula is epithelial
structure with which it communicates.
 Fistula is dangerous digest surrounding structure by
pancreatic enzyme lead to local damage, per foration,
bleeding.
 Immediate control obtains by nil by mouth – use
octreatide – drainage fistula.
 -Pseudo cyst collection of pancreatic juice enclosed in
wall of fibrous or granulation tissue that are following
attack of pancreatic.
 -Abscess: circumscribed infra abdominal collection of
pus usually in proximity to pancreas containing ultra or
no pancreatic necrosis.